I’ve always been curious about catatonia because it brings something into focus I’ve never understood, which I will try to explain. Mental illnesses as far as I can tell are physical illnesses. Calling them mental always confused me. I guess I see them as mental to the extent that a person make choices in their behavior and thinking. But the part of the illness that makes a person have different thinking or behavior is at least partially physical, even if the etiology is unknown (I understand there is also a social component). For this reason I’ve always thought of mental illnesses as syndromes: distinct patterns of behavior with unknown causes. Is there a reason not to view them this way and to refer to them as mental, e.g., mental health and mental illness?

I think the confusion for me and maybe other people is that with some disorders like anxiety or depression, there is an extent to which a person can affect their condition in ways that are somewhat indistinguishable from moral fortitude. There is an idea that a person can to an extent have will over their state. In those ways, the illnesses seem mental, but in the ways that they are out of a person’s control they seem physical (which I generally take to mean biological).

That’s why catatonia interests me. As I understand it, catatonia is an intractable state. A person who is catatonic cannot will themselves out of the state they are in. It’s not like having the alarm ring and refusing to wake up, even if it’s difficult.

So, I guess in some ways, to me that seems very clearly biological when a person doesn’t have will over it. Yet it can be caused by depression—something people can have will over to an extent. So my question is: Is catatonia, before it develops, invariable for the person it will affect? That is to say, if you could run a counterfactual on a person who has catatonia before they develop it and have that person do cognitive behavioral therapy, could it eliminate or reduce the chance a person would lapse into catatonia?

I think the flaw is simply lack of knowledge. Patients can't typically "will" themselves out of depression...to ANY extent. With therapy and/or medication sure. I have experienced that sometimes people do wind up receiving some form of "therapy" from unlicensed and untrained sources (friends, family, clergy, music, media, etc) and then people tend to attribute that they "willed" themselves out of it, when really they got some amount of minimal help and support, perhaps in the form of an empathetic friend going supportive "psychotherapy" or even a minimal CBT without realizing it. I've seen people with substance-induced depression hit rock bottom and stop using and stop being depressed too who also claim to have "willed themselves" out of their depression, when really what fixed their depression was stopping the substances. The point is that it's extremely rare for people to have any willful control over their psychiatric disorders. It's like asking someone to will themselves out of their HIV. "just get over it." "Have you tried not having HIV?"

The other "what?" point of confusion I think lies in the way your phrased your catatonia sentence. "A person who has catatonia before they develop it." I think you're asking about a person who has whatever biology underlies catatonia before the illness has presented itself to doctors, correct?

Listen, psychiatric disorders are 100% medical/biological disorders. There are flaws with the wiring and function of the brain. These flaws however are created by MANY factors, genetic, environmental, social, etc. They can also be fixed in many ways, from medications, which alter neurochemical signaling, to therapy, which can alter neuroplasticity. Either way you are re-wiring the computer that is the brain, and providing a biological treatment, whether it's in pill form or not, the end goal is to re-wire the computer.

I think the flaw is simply lack of knowledge. Patients can't typically "will" themselves out of depression...to ANY extent. With therapy and/or medication sure. I have experienced that sometimes people do wind up receiving some form of "therapy" from unlicensed and untrained sources (friends, family, clergy, music, media, etc) and then people tend to attribute that they "willed" themselves out of it, when really they got some amount of minimal help and support, perhaps in the form of an empathetic friend going supportive "psychotherapy" or even a minimal CBT without realizing it. I've seen people with substance-induced depression hit rock bottom and stop using and stop being depressed too who also claim to have "willed themselves" out of their depression, when really what fixed their depression was stopping the substances. The point is that it's extremely rare for people to have any willful control over their psychiatric disorders. It's like asking someone to will themselves out of their HIV. "just get over it." "Have you tried not having HIV?"

The other "what?" point of confusion I think lies in the way your phrased your catatonia sentence. "A person who has catatonia before they develop it." I think you're asking about a person who has whatever biology underlies catatonia before the illness has presented itself to doctors, correct?

Listen, psychiatric disorders are 100% medical/biological disorders. There are flaws with the wiring and function of the brain. These flaws however are created by MANY factors, genetic, environmental, social, etc. They can also be fixed in many ways, from medications, which alter neurochemical signaling, to therapy, which can alter neuroplasticity. Either way you are re-wiring the computer that is the brain, and providing a biological treatment, whether it's in pill form or not, the end goal is to re-wire the computer.

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By having will over something, I mean the ability to mitigate something—not to eliminate it. For example, a person with depression (as is often stated on this board) can go for a walk. Now I know it is not easy to do that. I know it is an incredible challenge. And I know that it doesn't do anything close to curing depression. If it did, everyone would go for a walk and be done with depression. What I was trying to refer to is the fact that with some mental illness, people have the ability to manipulate their body's system in some way to improve their condition, whether that is going for a walk or CBT.

I was trying to pair that understanding with a (psychiatric?) state called catatonia, in which it seems to me a person has no ability to have influence over their state. I feel as if far too often, mental illness is described as a lack of moral fortitude. But it occurred to me that it is difficult to make that argument when catatonia can result from a mental illness.

I actually agree with you about not being able to will oneself out of mental illness. I think I probably just use language in ways that are strange to people. I sometimes say either having will or cause over something to mean being able to influence the outcome of something. Maybe it's arcane, I'm not sure. In terms of the language about "a person who has catatonia before they develop it"--yes, that was not written very elegantly. I think with the context of counterfactual it makes sense, at least to me, but it's a bit overwrought.

Your explanation was actually the answer I was interested in. You're saying that no matter what you do: exercise, medication, CBT, electro-shock therapy, or even treatment for catatonia, it is a manipulation of the aberrations causing mental illness. That makes sense to me. But you can see in that understanding of mental illness, it seems to make no sense to call it mental illness.

It makes sense in the way that you can call heart disease "cardiac illness." The brain is an organ like any other, and it has it's own diseases, as the other organs do.

What I find really interesting is the border between psychiatry and neurology. I like to define it like this:

When the disease occur on a macroscopic level that we understand (we can see the changes on a CT, MRI, EEG, autopsy lesions, Gene sequencing, etc), it's "Neurological."

When the disease occurs at the microscopic level (receptors, neurotransmitters, poorly understood, not seen on imaging and lab tests), it's called "Psychiatric."

A number of disorders used to be "psychiatric." Most famous are the 7 Psychosomatic Illnesses from around the turn of the century: Asthma, Rheumatoid Arthritis, Ulcerative Colitis, Peptic Ulcer, Graves' disease, hypertension! and neuroses attics. Now, we understand these and find this naïveté laughable. 100 years ago, they were "psychiatric" problems. The day will come when "depression" (I hope) is a medical illness like the others...we're just a long way from that goal still.

It makes sense in the way that you can call heart disease "cardiac illness." The brain is an organ like any other, and it has it's own diseases, as the other organs do.

What I find really interesting is the border between psychiatry and neurology. I like to define it like this:

When the disease occur on a macroscopic level that we understand (we can see the changes on a CT, MRI, EEG, autopsy lesions, Gene sequencing, etc), it's "Neurological."

When the disease occurs at the microscopic level (receptors, neurotransmitters, poorly understood, not seen on imaging and lab tests), it's called "Psychiatric."

A number of disorders used to be "psychiatric." Most famous are the 7 Psychosomatic Illnesses from around the turn of the century: Asthma, Rheumatoid Arthritis, Ulcerative Colitis, Peptic Ulcer, Graves' disease, hypertension! and neuroses attics. Now, we understand these and find this naïveté laughable. 100 years ago, they were "psychiatric" problems. The day will come when "depression" (I hope) is a medical illness like the others...we're just a long way from that goal still.

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Very interesting (regarding illnesses that used to be considered psychiatric). Given that, it seems like psychiatric illnesses are similar to what people seem to call syndromes, such as chronic fatigue syndrome. I really think there is a misunderstanding of mental illness as somehow in the ether when it's described as mental. At least, I've always had a hard time getting my head around it. It affects mental processes, but the extent to which it is caused by a person's mental processes seems far less clear. I guess the word mental to me always connotes mind, which I think of as a tool people consciously use. For some reason I feel as if describing mental illnesses as physical illnesses that have mental effects would be more helfpul. The fact that until recently they didn't have parity under the law seems to indicate that, as well.

But you have helped me in confirming what I suspected about mental illness, that is just as biological but with poorer understanding of its etiology, much like what I've always assumed (correctly or not I don't know) the word syndrome to mean.

Edit: After I posted it made me wonder about people who are today diagnosed with somatoform disorder, given your examples. Are these patients considered to have an illness that has yet to be discovered as well?

When the disease occur on a macroscopic level that we understand (we can see the changes on a CT, MRI, EEG, autopsy lesions, Gene sequencing, etc), it's "Neurological."
When the disease occurs at the microscopic level (receptors, neurotransmitters, poorly understood, not seen on imaging and lab tests), it's called "Psychiatric."

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I'd say that if the illness is best monitored with a neurological exam (including MMSE), it's "neurological." If it's best monitored with a mental status exam, it's "psychiatric." I think that definition helps to resolve some of the gray areas, such as behavioral changes associated with "neurological" illnesses like Huntington's.

As far as the original discussion - I think it's just a question of the level of wiring dysfunction. MDD is a type of wiring malfunction that can be rearranged with neuroplasticity that is encouraged by good psychotherapy. Certain "happy" pathways might be like a road that's covered with a thin layer of snow, so it's hard to drive on it... but if a lot of cars start driving on it (i.e. strong CBT targeting that pathway), the snow disperses and melts and a pathway clears up. And antidepressants might have the effect of gradually increasing the temperature so that the snow melts. ECT might have the effect of pushing the snow out of the way with a big snow plow.

Catatonia is a weird state that we don't know much about. If MDD is like a road with half an inch of snow, catatonia might be the same road after an avalanche. At that point, it won't help to pave the way with other cars driving on the road. You need some heavy-duty equipment to come in and move the snow out of the way.
But that's not the best analogy because you treat catatonia with benzos, so it's probably associated with some neural pathway firing out of control and in need of attenuation.

As far as "mitigating" depression with certain behaviors vs. not being able to mitigate catatonia (or let's use a more common illness like schizophrenia) - I think you could say the same thing about illnesses in any other part of the body. You can improve CHF and/or CAD by eating better and exercising, but if you have myocarditis, you're not willing yourself out of it. It could also be related to etiology - if you have COPD from smoking, you'll get a bit better if you stop smoking... but if you have it from severe alpha-1-antitrypsin deficiency, there's no behavior that will fix you. If you have type 2 diabetes, you can improve your state with healthy habits; if you have type 1 diabetes, you have to take your insulin. Similarly, I think that if your MDD is actually caused by neuroplastic reinforcement of "negative" pathways due to a life marred by poverty, you might be able to use neuroplasticity to improve some of those pathways if you win the lottery. But if you have severe bipolar depression despite having had a pretty good outlook on the world for your entire life prior to the crash, then you probably need antidepressants to prevent the Hebbian plasticity of your depressed pathways from taking over your brain.

So I think that the basic flaw in your logic was to treat "mental disorders" as a single category that are entirely "biological" rather than "non-biological." Which is interesting, because your premise was that mental illnesses should be treated like any other illnesses. A good doctor should treat an illness as a multifactorial event that probably has roots in both genes and environment, whether that environment led to PTSD associated with sexual assault or coronary artery disease associated with fried chicken. Some of those illnesses will improve with behavioral changes, some won't. Behavioral changes are harder in psychiatry, since the illness affects your ability to make behavioral changes, but the lack of behavioral changes tends to worsen the illness.

By having will over something, I mean the ability to mitigate something—not to eliminate it. For example, a person with depression (as is often stated on this board) can go for a walk. Now I know it is not easy to do that. I know it is an incredible challenge. And I know that it doesn't do anything close to curing depression. If it did, everyone would go for a walk and be done with depression. What I was trying to refer to is the fact that with some mental illness, people have the ability to manipulate their body's system in some way to improve their condition, whether that is going for a walk.

I'd say that if the illness is best monitored with a neurological exam (including MMSE), it's "neurological." If it's best monitored with a mental status exam, it's "psychiatric." I think that definition helps to resolve some of the gray areas, such as behavioral changes associated with "neurological" illnesses like Huntington's.

As far as the original discussion - I think it's just a question of the level of wiring dysfunction. MDD is a type of wiring malfunction that can be rearranged with neuroplasticity that is encouraged by good psychotherapy. Certain "happy" pathways might be like a road that's covered with a thin layer of snow, so it's hard to drive on it... but if a lot of cars start driving on it (i.e. strong CBT targeting that pathway), the snow disperses and melts and a pathway clears up. And antidepressants might have the effect of gradually increasing the temperature so that the snow melts. ECT might have the effect of pushing the snow out of the way with a big snow plow.

Catatonia is a weird state that we don't know much about. If MDD is like a road with half an inch of snow, catatonia might be the same road after an avalanche. At that point, it won't help to pave the way with other cars driving on the road. You need some heavy-duty equipment to come in and move the snow out of the way.
But that's not the best analogy because you treat catatonia with benzos, so it's probably associated with some neural pathway firing out of control and in need of attenuation.

As far as "mitigating" depression with certain behaviors vs. not being able to mitigate catatonia (or let's use a more common illness like schizophrenia) - I think you could say the same thing about illnesses in any other part of the body. You can improve CHF and/or CAD by eating better and exercising, but if you have myocarditis, you're not willing yourself out of it. It could also be related to etiology - if you have COPD from smoking, you'll get a bit better if you stop smoking... but if you have it from severe alpha-1-antitrypsin deficiency, there's no behavior that will fix you. If you have type 2 diabetes, you can improve your state with healthy habits; if you have type 1 diabetes, you have to take your insulin. Similarly, I think that if your MDD is actually caused by neuroplastic reinforcement of "negative" pathways due to a life marred by poverty, you might be able to use neuroplasticity to improve some of those pathways if you win the lottery. But if you have severe bipolar depression despite having had a pretty good outlook on the world for your entire life prior to the crash, then you probably need antidepressants to prevent the Hebbian plasticity of your depressed pathways from taking over your brain.

So I think that the basic flaw in your logic was to treat "mental disorders" as a single category that are entirely "biological" rather than "non-biological." Which is interesting, because your premise was that mental illnesses should be treated like any other illnesses. A good doctor should treat an illness as a multifactorial event that probably has roots in both genes and environment, whether that environment led to PTSD associated with sexual assault or coronary artery disease associated with fried chicken. Some of those illnesses will improve with behavioral changes, some won't. Behavioral changes are harder in psychiatry, since the illness affects your ability to make behavioral changes, but the lack of behavioral changes tends to worsen the illness.